1

National Center for Primary Care

Morehouse School of Medicine

Integration: The New Buzz Word

George Rust, MD, MPH, FAAFP, FACPM

Father of Dan & Christina, Husband of Cindy,

Professor of Family Medicine

Director, National Center for Primary Care

Patient-Centered Medical Home Best Practice Model:

JCAHO-Accredited,

Patient-Centered, Open-Access,

Culturally-Relevant,

Community-Governed,

Quality-Driven,

Behaviorally-Enhanced,

System-Integrated,

Primary Care Health Home

• West Orange Farmworker Health

Association’s Family Health Centers circa

1989 -- Apopka, FL

Integration“We need a comprehensive,

integrated approach to service

delivery. We need to fight

fragmentation.”

-- WHO Director-General, 2007

Silos for a Healthier U.S.!

• Silos:

– Public health

– Medical care

– Behavioral Health

– Mental health

– Substance Abuse

– Faith Communities

– Neighborhood zoning

– Business / employees

– Legislators / policymakers

– Payors / Funders

Example: Why Do We Need Teamwork to

Improve Outcomes in Obesity & Diabetes?

Example: To prevent complications of obesity and

diabetes, all you have to do is modify a

person’s health beliefs and attitudes, daily habits, eating preferences, daily activities, exercise habits, grocery stores, neighborhood walk-ability, food advertising, self-care, employability, economic

empowerment, access to medical care, provider quality, and medication adherence, all in the context of his or her family and social relationships.

Silo: Separating Below-the-Neck

Obesity from Above-the-Neck

Motivations, Attitudes, and Emotions

The Continuum of Behavioral Health

Integration of What?

• Person-Level:– Primary Care / Behavioral health

• Practice-Level:– Panel-based Care Management

• Systems Level: – Information Systems

– Delivery Systems (Pharmacy, Specialty Care,

Emergency Dept, Hospital, etc.)

• Community Level:– Family and sociocultural context

– Social Determinants of health

• Population Level:– Outcomes Management (Accountable Care)

Mental Health ��Physical Health

“Baseball is 90% mental -- the other half is physical."

-- Yogi Berra

Cherokee Health Systems

“Integrated Care” Model:

2

Burden of Disease in

Industrialized Nations

Percent

of Total

All cardiovascular conditions 18.6

All mental illness including suicide 15.4

All malignant disease (cancer) 15.0

All respiratory conditions 4.8

All alcohol use 4.7

All infectious and parasitic disease 2.8

All drug use 1.5

WHO Global Burden of Disease

Murray CJL, Lopez AD, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of

mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: World

Health Organization and the World Bank, Harvard University Press, 1996. www.who.int/msa/mnh/ems/dalys/intro.htm

All Behavioral Health -- Mental Illness, Suicide, Alcohol, & Drug Use = 21.6%

Prevalence of Depression in Chronic Disease

Prevalence of Depression in Chronic Disease

51%

42%

23%

17% 16%12% 11%

27%

Par

kinso

n's

Can

cer

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IHIV

Alzhei

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's

Why Primary Care?Why Primary Care? Choices Real People Make

Diabetic

Patient with

Depression

Agree to Accept Referral and then Don’t Go

Accept Referral to Psychiatry Practice

Deal with Mental Health Problem in Primary Care Setting Only

Get Help X ���� ����

Avoid Stigma ���� X ����

Get Optimal Treatment

X ���� X

Coordinate Medical & Psych Rx

X ? ����

Clinical Scenarios

• Schizophrenia patient

gains 100 lbs, and

develops diabetes

• Bipolar patient on lithium

has hypothyroidism and

high blood pressure

• Diabetic patient with

depression

• Insomnia patient with

nervios

• CHF patient who

self-treats PTSD

with alcohol

• Chronic back pain

patient develops

opioid addiction

“Best-Practices” Integrating

Behavioral Health & Primary Care

• Cherokee Health System

• Intermountain Health

• Alaska Native Tribal Health Consortium

Behaviorally-Enhanced Primary Care

Gregory E. Simon, MD, MPH; Wayne J. Katon, MD; Elizabeth H. B. Lin, MD, MPH; Carolyn Rutter, PhD; Willard G. Manning, PhD; Michael

Von Korff, ScD; Paul Ciechanowski, MD; Evette J. Ludman, PhD; Bessie A. Young, MD, MPH Cost-effectiveness of Systematic Depression Treatment Among People With Diabetes Mellitus. Arch Gen Psychiatry. 2007;64(1):65-72.

Why Does Mental Health

Need More Primary Care?

• S Brown. Excess mortality of schizophrenia. A meta-analysis The British

Journal of Psychiatry 171: 502-508 (1997)

• 25-year survival deficit --

Schizophrenia Excess Mortality

• 28% due to ↑ suicide

• 12% due to ↑ accidents

• 60% due to ↑↑↑↑ everything else

Continuum of Integration

Separate Referral Coordinated Collaborative Integrated

Separate Co-Located Common

Coordinated Care

• Tracking & Confirmation

of Referrals & Follow-up

• Sharing of Medical Records

• Sharing of Prescribing

Changes & Medication Lists

• Inter-Operable

Electronic Health Records

• Mutual Participation in Effective

Health Information Exchange

3

Collaborative Care

• All of the Above plus . . .

– Team-Based Case Conferences

– Frequent Interaction on Therapeutic Strategy

– Patient-Centered, Shared Decision-Making

– Shared Care Management

– Joint Decision-Making on

Medication Changes

– Frequent, secure communication by

phone, e-mail, & videoconferencing

The Power of Integration

What would

happen if all

the health

professionals

came

together and

created a

therapeutic

community of

healers for

whole

people?

Faith

Communities

Mental

Health

Substance

Abuse

Treatment Primary

Care

Patient-Centered Medical Home

Primary Caring-- Healing

with our “Radical Human Presence”

• Listening

• Touching

• Affirming

• Comforting

• Diagnosing

• Treating

• Grieving

• Supporting

• Healing

Radical Human

Presence is a

phrase used in a

presentation

called “How the

Heart Learns”

by Landon

Saunders;

AAMFT, 2004

annual mtg.

Is Primary Care Part of the Problem?

•Usual

Care = Sub-

Optimal

Care

NCQA / HEDIS Quality Measures for

Comprehensive Diabetes Care

Quality

Indicator

Performance

(Medicaid)

Performance

(Medicare)

Performance

(Commercial)

A. Good HbA1c

Control (< 7)30.9% 45.9% 41.8%

B. Partial BP

Control (<140/90)57.3% 57.8% 61.4%

B. Good BP

Control (<130/80)30.4% 30.2% 29.9%

C. Cholesterol

Control (LDL <100)30.6% 46.9% 43.0%

Primary Care in

Underserved Settings

• Uninsured Patients

• Limited Resources

• Cultural & Linguistic Barriers

• Professional Isolation

Five Preventive Services Could

Save over 100,00 Lives*

• Aspirin advice � 45,000 lives

• Smoking advice � 42,000 lives

• Colorectal CA screening

� 14,000 lives

• Flu shots � 12,000 lives

• Breast CA screening � 3,700 lives

116,700 lives

* If we increased from current levels of performance to 90%.

4

Teamwork! • Community Health Workers

(Promotoras)

• Medical Assistants

• Nurses / Nurse Practitioners

• Pharmacists

• Social Workers

• Health Educators

• Oral Health Professionals

• Physical Therapists

• Primary Care Practitioners

• Psychologists

• Behaviorists

• Sub-Specialty Physicians

• Administrators

Nurse Care Managers

• Impact of a diabetes

resource nurse (DRN)

case manager in a

suburban 12-physician

family practice on

quality care and

outcomes

Proc (Bayl Univ Med Cent). 2003 Jul;16(3):336-40. Clinical outcomes in patients with type 2 diabetes managed by a diabetes resource nurse in a primary care practice. Couch C, Sheffield P, Gerthoffer T, Ries A, Hollander P. Family Medical Center, HealthTexas

Provider Network, Baylor Health Care System, Garland, Texas, USA. ce.couch@BaylorHealth.edu

7.2%6.6%

8.9%

6.8%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

Geriatric Non-Geriatric

Before

After

Teamwork! Enhanced Asthma

Education via Community Pharmacists

– Symptom scores � 50%

– PEFR values � 11%

– Beta-Agonist Use � 50%

– Days off school / work � 0.6 days/month

– ED Visits � 75%

– Medical Office Visits � 75%

– Quality of Life Scores � 19%

McLean W, Gillis J, Waller R. The BC Community Pharmacy Asthma Study: A study of clinical, economic and holistic outcomes influenced by an asthma care protocol provided by specially trained community pharmacists in British Columbia. Can Respir J. 2003 May-Jun;10(4):195-202.

Teamwork: LPN’s &

Medical Assistants (every team member working

up to the level of his/her license)

68%

77%

66%67%

60%

62%

64%

66%

68%

70%

72%

74%

76%

78%

Intervention Control

Before

After

• McCarthy BD, Yood MU, Bolton MB, Boohaker EA, MacWilliam CH, Young MJ. Redesigning primary care processes to improve the offering of mammography. The use of clinic protocols by nonphysicians. Gen Intern Med 1997 Jun;12(6):357-63

• Example: Empower

More Clinical Staff

to Initiate Preventive

Services • Medical assistants and

Licensed Practical Nurses

offer mammography as a

routine part of the clinic

encounter

DCA 2000: $8 / test

•CLIA waived

•Reagent-filled cartridges

•6 minutes to test result

•Also does micro-albumin

and Creatinine

Make

Excellence

Automatic

• Measure A1c on

every diabetic visit

A1c Now: $13 / test

•CLIA waived

•No maintenance - disposable

•8 minutes to test result

•Fingerstick or venipuncture

•FDA cleared for home use Bayer DCA2000

Staffing Models:

(8,000 patient

panel)

• 5 MD’s

• 2 PA’s

• 1 RPH

• 2.5 MD’s

• 3 PA’s

• 1 NP/Care Mgr

• 1 LCSW or

Psychol/Behav

• 1 DDS + hygienist

• 1 Pharm D

(+ pharm tech)

• 3 Promotoras

Systems Change :

Information Systems

• Use Information

Systems at the

Individual Patient

or Visit Level

• Example: Flags, triggers,

etc. to promote

compliance at each visit

and to decrease missed

opportunities

Don’t forget long-term control Rx!

Uncoordinated Care –

When We Just Don’t Talk

• Eleanor Rigby – 37 y/o F w/ Bipolar Disorder

– Lithium (Lithobid®)

– Aripiprazole (Abilify®)

– Divalproex Sodium (Depakote®)

• Eleanor Rigby – 37 y/o fertile female smoker with

HTN & two-weeks of productive cough

– Azithromycin (Zithromax Z-Pack®)

– ACE + HCTZ (Vaseretic®)

– OCP’s (Yaz®)

– Bupropion (Zyban® or Wellbutrin®)

Health Information Technologies

• Practice Level:

• Average A1c level

in all diabetics

• % of Patients with

A1c > 8

• Lists of patients

with A1c > 8 for

outreach / action

Individual Level:

• Flags or triggers to

promote compliance

at each visit and to

decrease missed

opportunities

• Evidence-based

guideline alerts

5

Re-Engineering ��� “Lean”

• Maximize process speed

• Define “value-added work”

vs. non-value-added work

• Eliminate waste (non-value-added work)– Unnecessary Steps

– Unused Human Potential (LPN not working up to license)

– Unnecessary Waiting Time

– Backlog (charts, people, billing claims, etc.).

– Unnecessary Human Motion (physical distance)

– Defects (Work that Needs to be Fixed or “Done-Over”)

Re-Engineering ��� Lean

Front-Desk Check-In

Appointment

Phone Calls

Medical Records

Nursing – Vital Signs

Clinician Visit

Pharmacy Lab Tests

Cashier /

Check-Out

Waiting Room

Tele-Health

Home Monitoring

High Tech � High Touch

• Framingham Risk

Calculator for PDA

Appropriate

Technology

Teamwork Includes Patients!

• Keep Patients on the Team!

• Patient Self-Management Education

Cochrane Database Systematic

Review (2003): Patient self-

management education reduces

relative risk of adverse outcomes:

• Hospitalizations RR = 0.64

• ED Visits RR = 0.82

• Days off work or school RR = 0.79

• Nocturnal Asthma RR = 0.67

Caveat: Little change in measurable

lung function

Doctor-Centered Medical Home:

the Exam Room and the

Doctor-Patient Visit

Teams that Match

Patient Realities

• Diabetic patient

• Eats at Irregular Hours

• Episodes of Hypoglycemia

� Migrant farmworker

�� Leaving tonight riding in back Leaving tonight riding in back of covered pickup truck to of covered pickup truck to drive 12 hours to pick drive 12 hours to pick yams in Ohioyams in Ohio

�� 1313--hour workday tomorrowhour workday tomorrow

�� No control over when she eatsNo control over when she eats

Community Health Workers

(Promotores de Salud)Silo #2: Separating

Healthy Kids from

Healthy Communities

The Continuum of Community Health

6

Promotores / Promotoras &

Community Health Workers

� Enhanced Access to & Use of Complicated Health Systems (Navigators)

� Immunization Rates

� Breast & Cervical Cancer Screening

� Blood Pressure Control

� Control of Asthma Triggers in Households

� Healthy Eating & Exercise

� Safety Eyeware Use Among Farmworkers

� Compliance with Directly-Observed Treatment of Tuberculosis

Patient-Centered Medical HomePrimary Care Community Health Centers

Impact on Uninsured ED Visits

31% Excess

62% Excess

No CHC = 37% Excess ED Visits

Disparities = Human Tragedy

•A baby dies every day in Georgia, and

would not have died if there was no

black-white difference in infant

death rates

Unequal Care & OutcomesMental Health Co-Morbidities in the

Disabled Medicaid Population

49.0%28.0%35.7%52.5%5.1%1,798 Asthma

38.5%22.5%25.6%61.0%5.7%1,998 Cancer

47.1%29.2%30.7%77.6%6.0%2,099 Blood (not hemophilia)

44.0%30.7%25.1%87.3%6.1%2,130 Coronary Dz (CAD)

44.1%28.5%27.5%81.6%6.7%2,365 Vascular

41.9%28.4%24.9%78.4%7.2%2,530 Heart (not CHF/CAD)

56.1%38.2%35.7%75.4%8.4%2,944 COPD

100.0%100.0%48.5%72.7%10.6%3,735 Substance Abuse

32.9%14.2%25.0%67.1%14.8%5,187 Diabetes

39.4%17.8%29.7%63.2%21.6%7,613 Lipid / Metabolic

42.4%19.8%33.1%54.6%24.7%8,683 Musculoskeletal

36.5%17.6%26.7%60.2%30.0%10,545 Hypertension

% among Pop wth this Dx who also have

either Mental Health or

Substance Abuse (or both)

% among Pop with this Dx

who also have any

Substance Abuse

% among Pop with this Dx

who also have any Mental

Health Dx*

% among Pop with this Dx who also have at least 3 Other Co-Morbid Diseases

Prevalence of this

Diagnosis in adult,

non-pregnant

ABD Population n

Disease Diagnosis (Dx)

Diseases Associated with High Co-Morbidity Rates (> 50% with >3 comorbidities)

49.0%28.0%35.7%52.5%5.1%1,798 Asthma

38.5%22.5%25.6%61.0%5.7%1,998 Cancer

47.1%29.2%30.7%77.6%6.0%2,099 Blood (not hemophilia)

44.0%30.7%25.1%87.3%6.1%2,130 Coronary Dz (CAD)

44.1%28.5%27.5%81.6%6.7%2,365 Vascular

41.9%28.4%24.9%78.4%7.2%2,530 Heart (not CHF/CAD)

56.1%38.2%35.7%75.4%8.4%2,944 COPD

100.0%100.0%48.5%72.7%10.6%3,735 Substance Abuse

32.9%14.2%25.0%67.1%14.8%5,187 Diabetes

39.4%17.8%29.7%63.2%21.6%7,613 Lipid / Metabolic

42.4%19.8%33.1%54.6%24.7%8,683 Musculoskeletal

36.5%17.6%26.7%60.2%30.0%10,545 Hypertension

% among Pop wth this Dx who also have

either Mental Health or

Substance Abuse (or both)

% among Pop with this Dx

who also have any

Substance Abuse

% among Pop with this Dx

who also have any Mental

Health Dx*

% among Pop with this Dx who also have at least 3 Other Co-Morbid Diseases

Prevalence of this

Diagnosis in adult,

non-pregnant

ABD Population n

Disease Diagnosis (Dx)

Diseases Associated with High Co-Morbidity Rates (> 50% with >3 comorbidities)

Unequal

Benefit –

Breast

Cancer

Adoption S-Curve

Isolated or disenfranchised

or non-majority

cultural groups

Focus on Global Health Outcomes for Complex

Mental Health & Medical Co-morbidities

ip op md ot m2 dg total

$217,657 $7,105 $29,756 $10,498 $3,155 $12,182 $280,353

One Diabetic Patient:• Diabetes

• Arthritis

• COPD

• CHF

•Stroke

• Pneumonia

• Cancer

• Depression

•Alcohol / substance abuse

* 21 ER Visits * 143 hospital bed-days

7

Drivers of Health Disparities

Health

PotentialWorst

Minority

Average

Majority

Best / Optimal

Excess Cost Due to Racial Variation

in Hospital Admissions by Disease(mid-range estimate)

Excess

Hospital

Admissions

(mid-range)

Hospital Charges Attributable to Excess

Hospital Admissions

(mid-range)

Payer Costs Attributable to Excess

Hospital Admissions

(mid-range)

Asthma 2,044 $28,687,330 $13,339,608.45

Diabetes 3,955 $92,172,057 $42,860,006.51

Heart Disease 5,021 $187,289,234 $87,089,493.81

>Coronary

Artery Disease 1,287 $65,156,724 $30,297,876.66

>Congestive Heart

Failure 5,868 $162,561,372 $75,591,037.98

HIV 1,644 $76,784,134 $35,704,622.31

$ $ Charges Due to Uninsured Hospital

Admissions (All-Cause & ACS Conditions)

Hospital Admission Hospital admission for ACS Condition

age group Count Rate/100,000 Total Discharge

$$ Charges $$Count rate/100,000 Total Discharge

$$ Charges $$

<1yr infancy 3381 2166.8 13052692 30 19.2 240085

1-4 early childhood 533 89.6 4982660 278 46.7 1882363

5-12 later childhood 515 44.7 5938480 221 19.2 1914935

13-19 adolescence 2179 225.5 38505983 417 43.2 5008118

20-29 early adulthood 11959 847.1 295608834 2546 180.3 37563398

30-44 young adulthood 21240 1005.7 509586602 4801 227.3 80410161

45-59 middle adulthood 26799 1375.4 779924179 6409 328.9 124391039

60-74 later adulthood 6130 583.6 212189003 1379 131.3 28830299

75+ older adulthood 438 100.4 15137085 74 17.0 1829954

Sum $1,874,925,518 $282,070,352

Table 3. Uninsured patient hospital admission/ hospital admission for ACS condition

count and rate per 100,000 population and total hospital discharge by age group among Georgia residents in 2009

$

Indigent Care Hospital Costs (assuming

35.6% cost to charge ratio) – all-causes of

hospital admission

Indigent Care Hospital Costs (assuming 35.6%

cost to charge ratio) –hospital admissions

due to ambulatory care sensitive conditions

$667,473,484 $100,417,045

Closing the Loop,

Accelerating Cycle Times

• Practice-Level Data

• Monthly ED Visit Rate

• Hospital Bed-Days

• Preventable Adverse Events

• Person-Level Feedback

• Missed refills

• Inadequate Care

• ED Visit yesterday!

Triangulate Interventions

Children

Schools

Primary

Care &

Public

Health

Family &

Community

Psychologists &

Behavioral Health

Community-

Oriented

Primary Care

Moving Toward Optimal Health for All

in the Agalto Valley, Honduras

In the 1980’s, Infant Mortality

in the Olancho state of

Central Honduras was over 70

per 1,000 (7%); Since 2006,

there have been no infant

deaths in the 27 villages

covered by the comprehensive

community development

work of Honduras Outreach

(Rancho Paraiso)

What Accounts for Success

in the Agalto Valley, Honduras?

Was it Social Determinants?

Agricultural Development Pre-K & Kindergarten

Vocational Training Community Organizing

What Accounts for Success

in the Agalto Valley, Honduras?

Was it Public Health & Sanitation?

Latrines / Waste DisposalSafe Water to Households

Safe Housing / Indoor Air

Malaria PreventionSafe Housing / Chagas Dz

8

What Accounts for Success

in the Agalto Valley, Honduras?

Was it Health Literacy & Nutrition?

School –based Meals Nutrition Education

Nutrition Education Intensive Center for Mother-Child Malnutrition

What Accounts for Success

in the Agalto Valley, Honduras?

Was it Primary Care / Prenatal Care?

Satellite Clinic Nurse AuxilliairesFamily Practice Physician

Pediatric CarePrenatal UltraSounds

What Accounts for Success

in the Agalto Valley, Honduras?

Or Was it a Comprehensive, Integrated Approach?

Economic & Community Development

Prenatal Care / Primary Care

Public Health / SanitationEducation / Nutrition

Tying it All Together to Achieve

Optimal, Equitable Health Outomes

Community Health

Promotion

Health Outcomes

Primary Care

Medical Home

Accountable

Health Care

Entities

Think what

we-all could

accomplish

together!

29 babies saved!!!

Disparities Success Stories!

Decline represents 29 infant deaths prevented

(expected vs. actual)

Create A Real System of Caring

at the Community-Level

Emergency

Room

Primary Care

Mental

Health

Business &

Community

Leaders

Hospitals

Public

Health

Faith

Communities